Here’s to a Speedy Recovery? Not So Fast!

Alan came in yesterday and he put it right out there. “I was really disappointed with our visit last month.”, he shared. “I expected to lose more that the 6 pounds given all the work I had done”. More than a pound per week achieved through his modest dietary changes and his move from a sedentary activity level wasn’t enough. Sure he was feeling better—sleeping better, less heartburn, more energy—but still the weight loss wasn’t enough.

Thinking this portion should satisfy? Maybe not!

I wish I could say this was an atypical occurrence. Rather, many a patient, and a parent, present painfully honest about their dissatisfaction. Not with me, I’ll add, but with themselves, their child, their spouse. Really, they struggle to make sense of the reality of changing behaviors with their vision of what should be.

And if you’re like them, it’s not your fault for struggling with this. Ever watch The Biggest Loser? Those who get thrown off the show for not losing fast enough lost 7 or so pounds—in only one week! How about those Jenny Craig and other diet program ads—the ones with those alluring before and after photos with the oh-so-tiny-print revealing for legal reasons, that “results are not typical”? (For the record, losing rapidly will ultimately result in rapid weight increase, preoccupation with food and weight and a host of other consequences).

Perhaps you’re dealing with an eating disorder. These past 2 weeks I’ve watched as my patient’s insurance company repeatedly rejected her pleas for treatment. Alison long struggled with anorexia and bulimia and after much work on the part of her providers (myself included) had agreed to enter a program. I thought that was the hard part. But then the tables turned and she became the one who had to fight for coverage for appropriate care; in the eyes of the insurer, 15 or 20 years entrenched in her eating disorder should surely be remedied in a couple of weeks in a program! Even her providers at the treatment center—no doubt influenced by the regulations and coverage struggles they’ve come to accept—seemed to take that stand, despite her recent slip when left on her own.

You just might encounter some obstacles.

Your difficulties in recovery may be influenced by your unrealistic expectations of the process of recovery or of changing behavior. Like Alan, you may take a “why bother?” approach and throw caution to the wind, sabotaging your progress because you sense you’ve already failed.

Sarah’s parents recently emailed me concerning their anorexic teenage daughter whom I’ve been working with. “She’s been making a point of going out more for dinners and she’d stopped keeping a food record”. Potentially cause for alarm? Maybe. But in Sarah’s case it was anything but. She had make remarkable progress with weight restoration over the preceding months and had been forthcoming about her difficulties—when they occurred. The dinners out? Now that she was more comfortable eating in restaurants and having others prepare her food she was stepping out; it was not an attempt to avoid parental mealtime supervision. And the lack of record keeping? Sarah was working on moving toward more intuitive eating at this point, and we had agreed to move from the daily food logs and exchange list accountability. I am not faulting involved parents in the least. But sometimes change is a good thing, as in Sarah’s case.

Some families expect recovery to be like ER treatment—you come in in a crisis, you get emergency treatment, like surgery or a new medication and you’re discharged to home and fixed. Unfortunately, eating disorder recovery is nothing like this.

So what to do when you live in a world filled with outrageous messages and your unrealistic timeframe for change is far from attainable? Focus on the immediate benefits of the positive changes you’re making, versus dwelling on the disappointments and frustrations. Consider not just the shoulds, as in “I know I’m supposed to be eating better, so that’s good” or “I know that this will help me down the road to prevent heart disease”. 

Don't expect to feel so positive all the time!

Consider the benefits many of my patients shared this week:

• my energy level is so much better

• I’m thinking more clearly

• I’m less preoccupied with what, when, how much to eat and I’ve stopped counting calories!

• my worst fears haven’t come true, in spite of my resistance to making the changes

• it’s getting easier to do the tasks I initially struggled with

• I’m seeing the impact of my role modeling on my young kids

• I was able to have a scoop of ice cream and trust that it would be there if I wanted more later!

• I baked and ate what I baked for the first time in years! (from Food to Eat, I’ll add!)

I also saw improved blood sugars in diabetics—with less than Biggest Loser amounts of weight loss, and I heard from both patients and families about improved mood and decreased irritability.

I realize that the positives, like those described above, may also occur side by side some negative experiences. For those starting to eat more as instructed, the physical sensations can be challenging. And anxiety, for many, is a real challenge and may need to be tackled with support from your therapist and MD. I don’t want to paint an unrealistic rosy picture, suggesting that all you need to do is adjust your thinking!

We’d all like a speedy recovery, as the expression goes. But in order to move there, we just might need to adjust our expectations.

Remember Patience?

Your thoughts?

Weight Loss and Recovery—Can they Coexist? Is Recovery Even Possible After So Long?

Remember Maggie who lost over 150 lbs.?

She’s experienced them all—she’s been labeled with anorexia, bulimia and BED (binge eating disorder)—now an official diagnosis in the new DSM-5, the manual of mental health diagnoses. And she’s been categorized as obese. She did not seek treatment for her disorders early in her history, when recovery is known to be more likely. Yet she’s done it, she recovered. And she didn’t truly start the process until she was in her 60’s.

Hooray for Maggie! Recovery is possible!

I'm writing about Maggie, once again, to offer hope that recovery is possible. Because it is. And because you may believe that even if you did recover, that you would never maintain it. And that it’s not even worth starting on the path, because you just might fail. There. I’ve said it. Now let’s move on.

About Maggie, present day.

This lovely, now 74-year old woman with a long history of eating disorders, has maintained her consistent recovery—and then some. If you haven’t read about her history through Feb 2011 in the link above, please read it now to appreciate where she’s been.

First, the stats. As of today, Maggie's weight is down from her initial weight of 387 pounds (back in 2002 when we started our work together) to 212 lbs. Yup, that's 175 lb. decrease. Most notable, though, is that she achieved this through healthy measures, normalized food intake, a move from binge eating and without disordered behaviors. I don’t think you’ll find the Biggest Loser winners accomplishing such behavioral goals, given the crazy-extreme measures they take on the show.

But let's look at the markers of health that really matter: her A1c, the measure of blood sugar control over a three month period, is now normal for this diabetic woman (it was out of acceptable range even for diabetics, previously). And she is no longer on the blood sugar-lowering medications she had relied on twice daily. All of her lipid measures (think cholesterol) dramatically improved, too. ‘Maybe it's the meds?’ ‘Don't statins do a great job at that?’ Well, her statin dose was cut in half. And statins do little to nothing to improve HDL, the 'good' cholesterol—yet hers improved significantly. As did her triglycerides (down 150 points), also not attributable to her medication! At 212 pounds, her cardiac risk ratio is lower than most individuals’ by far.

Maggie eats more than she ever recalls allowing herself to eat at any other time in her life—aside from pregnancy. She consumes regular meals and snacks daily. She does a water exercise program a couple of times per week—she's even overcome her anxiety of being in the water, with the assistance of a great therapist.

It's a lot of hard work, and you might get off course.
But you'll be glad to get there in the end.

It's been neither a few months, nor a whole year. Rather, it's been 11 years since we started our work together. Yes, it's a process (although not this long for everyone, I'll add). But Maggie only started her journey when she was 62, after about 50 plus years living with disordered eating and beliefs about what she deserved to eat and how to nourish her body.

Patience, dear readers. You can’t expect to undo a decade or a lifetime of unhealthy thoughts and behaviors in a couple of months.

Maggie’s next step is to believe that she's just fine as she is—high BMI and all; that weight loss shouldn't be the focus. It’s not so easy, though, given that her whole life her worth was tied up in the number on the scale. Even when those who constantly criticized her appearance were gone, she picked up where they left off with her own negative self-talk. It seemed the damage was done.

But can’t she still lose weight?

If she continues with her eating on course, and she feels well, and her weight continues to decrease—there's no problem with losing more weight, as long as her thoughts are kept in check. But I'm emphasizing that the goals that really need to be met, have been: she's taken control of her health, she's more fit than she's been in years, and she's eating more adequately than ever before. There's no binging or deprivation, and no compulsive exercise. And she feels well—physically and mentally. So we’ll just need to proceed with caution, because weight loss is a slippery slope for triggering eating disorders.

I hope Maggie will check out this blog (she has given me permission to write about her again, with her name change of course!) And I anticipate she'll see from your comments how she has inspired you and others to not give up and to have hope that change is possible. Yes, recovery really is possible.

Please share your thoughts with us!

Thinking the Work is Complete Now That Your Weight Has Changed?

Lessons from co-writing Food to Eat: guided, hopeful & trusted recipes for eating disorder recovery.

Last week I saw a new patient, a 50 something year-old overweight woman who presented with the stated goal of improving her health—and taking control of her escalating weight. Her body language and her attitude shouted ambivalence—or more accurately, defensiveness—and within the first quarter hour she had me on the defensive, too. Not too much rocks my boat, given 26 years seeing patients, including those who'd rather not be there. But the accusatory tone in which she asked about my weight history startled me. While not speechless (imagine what it would take for that to happen!) I was certainly at a loss to articulate my credentials to help her in a way I thought she could hear. Perhaps even expecting that she would hear was setting an unrealistic goal.

Can I ever REALLY know how difficult his life is? Or what he's thinking?

What could I possibly know about her weight struggle, was what she implied. How could I—a slim appearing, seemingly confident person — know about her challenges? Who am I to be giving advice? Well it wasn't the first time I had heard such questions, but for some reason her's threw me off guard. How do I begin to explain that my weight has nothing to do with my knowing, and with my ability to help? (Do I need to share my personal struggle with weight—which I openly discuss in my new book, Food to Eat, coauthored with Cate Sangster—which should have no place in our session about her?)  

What does weight have to do with it?

And if I had been a fat nutritionist, would that have validated my skills in guiding her on her recovery path? I suspect not, as I have heard many a criticism of dietitians' weights that has made me cringe over the years. That is, unless they were able to look past size and weight bias and hear the value of my words, as the Fat Nutritionist proves worth doing.

For those of you struggling with an eating disorder, you may feel similarly. Just because you are weight restored or nearly so, doesn't mean your disordered thoughts have abated. My co-author Cate, even when in a physically healthy place, is no stranger to these intrusive thoughts. And she shares them so openly with raw emotion—exposing her fears and her wishes relating to food and eating. But what does the public know when they see Cate or you on the outside? No, it's not just the stereotypical 60-pound-anorexics that suffer from eating disorders.

And what assumptions, what projections do you make, about what they are thinking about you? Do we have any idea what anyone struggles with unless their appearance is extreme? Would people know I live with MS when I am not wheelchair bound nor walking with assistance? Do they know about your closet eating? Your food hoarding? Your bulimia? Your obsessive calorie counting and weighing and body checking?

Being exposed.

In a similar way, completing the book leaves us both vulnerable. How will it be received? Will it look good? Will it be criticized and viewed as flawed? Will it be taken seriously? Will it have been worth the struggle to do the work? Will readers, like last week's patient, wonder what we could possibly know about the struggle to improve your relationship with food?

Can you even see the distortions?

I think not. Cate and I have been painfully honest, sharing—perhaps for the first time—about our own histories and relationship with food. We are not naïve enough to believe that this one book will solve your eating disorder—your bulimia, anorexia or compulsive overeating.  But we believe deeply that it is immensely valuable in changing your thinking and getting yourself eating with more peace. In spite of our fears, we've put ourselves out there and have taken the risk of exposing ourselves.

Quite frankly, I never dreamed that experts in the eating disorder community would take the time to thoroughly review our book. And then to provide valuable criticism that would really enhance it. I certainly didn't expect to receive the praise we got. Really, I am humbled and flattered beyond words.

I owe thanks to Laura Collins, author of Eating With Your Anorexic and a leader in supporting families living with eating disorders, for pointing out our blatant omission of families—both as a target audience for the book, and in their role supporting those struggling to prepare food and to eat.

And to Dr. Lydia Shrier of Boston Children's Hospital Adolescent Clinic and Harvard University, for highlighting our need to think more broadly about genders and partners and spouses in the book.

To have virtual strangers and mere professional and cyber acquaintances—Dr.Cynthia Bulik, the well-published researcher, author and public speaker; CarrieArnold, author of Decoding Anorexia, known to me from her ED Bites blog; Dr. Suzanne Gleysteen, with whom I've shared so may eating disorder patients; Dr.Therese Waterhous, a dietitian at the forefront of the eating disorder field; Dr. Wendy Oliver-Pyatt, from Oliver Pyatt Centers; and MEDA, the Multi-service Eating Disorder Association—think enough of Food to Eat to write fabulous, glowing reviews, exceeded all of my expectations.

Getting exposure?

Flying high, but feeling rather vulnerable.
Won't you provide the safety net?

I believe in Food to Eat and its value like I believe that recovery is possible. I regret that, due to its beautiful printing is full color, it needed to be priced to cover the large costs of production and distribution to Amazon and bookstores. (Purchases of the print version outside of Create Space and Amazon yield a shared profit of $.04, for the record!). We do not expect to get rich on this project, which has taken the two of us almost a year to complete. But we do hope to make a difference.

Can you help? If you buy a copy via Kindle or Amazon, will you kindly write a review? And if you buy it through Create Space please add your review to our comments page on food-2-eat.com.

Can you demonstrate the power of social media, and share a link or a comment on Facebook, or Twitter, Pinterest or Google Plus? Or even on your blog if you write one?

And please contact me or Cate with feedback on the book, any feedback. Yes, we all need to be prepared for criticism!

Thanks for listening!

Lessons About Eating Disorders

What I Learned at the AED Meeting

I’ve exceeded my 1 week limit between posts, but I’ve got a really good excuse—I’ve spent the past 4 days at the Academy of Eating Disorders (AED) Annual Conference. So I thought I’d share some personal and hopefully meaningful observations about eating, recovery, and miscellaneous thoughts:

• Day one, 4 hours of workshop, and what did they serve at the refreshment break? Coffee, tea and water. Period. And I wanted calories. Food. I was hungry. Half a day learning about a treatment for anorexia and I couldn’t find anything to eat! But it only got better from there—really.



One of several courses eaten at Barley Swine

• I spent a large percentage of my 24 hours each day doing 2 things—learning about eating disorders and planning and arranging to eat—where to go, whom to go with, and what to order, to name a few. And I must say, Austin Texas has some fabulous food! My top picks?  Barley Swine and La Condesa—simply divine!

• Another evening we were 8—two in recovery from anorexia with 3 RDs, 2 therapists and a mom/eating disorder advocate—all eating out together. Can you even imagine? From my perspective it was fabulous. How about a round of applause for those recovering, brave enough to endure such a dinner?
• People appeared better in person than they had on the web. No, I’m not speaking of their physical attributes. But in person, their energy and warmth radiated, adding a whole level of beauty that truly got missed on line. Thoughts were shared and clarified without misunderstanding—it sure helps when you have more than 140 characters to explain yourself!

• Two of the diners are bloggers that I had a somewhat rough start with in the virtual world. Carrie and I, as I recall it, had long ago debated the implications of viewing eating disorders through the lens of biology, much as a conference panel debated labeling eating disorders as brain disorders. While Laura helped shake up my thinking on Family Based Treatment, yet supported my perspective about the important role for dietitians, typically omitted from this therapy.

Carrie, Cate and I before dinner.
(We didn't look any different after dinner, though!)

• Conflict leads to learning and change. If we all stuck with our same ways of doing things we would never grow and develop. We would perhaps feel safe, but would truly stifle our potential, our recovery even.
• Cate and I met for the first time, in spite of feeling I have known her forever. We met through this blog and we have inspired each other to change as well. And you’ll soon hear details about our upcoming book!

Dessert shared with another RD

Meaningful messages from the AED meeting

Connection

Connection helps recovery. A family member, treatment provider, friend, an internet-mentor—even one strong connection can make a difference. And involving your partner shows great promise, based on the research by Cynthia Bulik, PhD and Donald Baucom, PhD. So if you haven’t begun to share with your significant other, or no one knows your struggle, perhaps it’s time to change that.

Hope

“You’re the first person who ever told me I can recover”, I’ve been told far too many times. It is unfortunate. Recovery happens (a bumper sticker, perhaps?), but it doesn’t occur passively. It certainly takes work, your hard work, and a great deal of time. And there are slips, which you must prepare yourself for. Because slips happen (ok, another bumper sticker?) I hope those of you outside the states get the reference to a US bumper sticker—Shit Happens—it would be much funnier if you did!

So if your provider tells you that you can’t recover, then it’s time to find a new provider.

Blame

Blame is useless. Your mother didn’t cause your eating disorder, nor did your ex-boyfriend. Sure, environment can play a role in the development of eating disorders (just as perhaps your genetic predisposition and your personality type may have contributed). But it is most ineffective to focus on “why did I get this condition” or to blame yourself asking “what’s wrong with me, why can’t I change?” We all want answers, but the truth is, what we really need are solutions. And blame is clearly an obstacle to getting there.

Eating disorders are serious

I liked Laura (Collins) Lester-Mensch’s suggestion that we refer to eating disorders as treatable brain disorders. Sounds so serious, no? Even a bit scary—and rightfully so. Eating disorders need to be taken seriously. One in 10 people die from their eating disorder. And delaying treatment only makes the challenge greater for recovery. While we don’t know whether the brain is involved from the start of the eating disorder or as a result of the eating disorder, here’s what remains—the brain is involved, and nourishing it aids in recovery of the disordered thoughts, mood changes and of course, the physical consequences. The brain is not static—it is flexible, plastic, and changeable.

Perhaps viewing eating disorders as treatable brain disorders will allow us to have hope, remove the blame, and inspire us to connect with others without shame to support recovery.

As always, I care to hear your thoughts and reactions to these posts.

The Quick Fix For Your Struggle With Eating? Patience.

20 years to construct Chateau de Chambord,
Loire Valley, France

I know you’re impatient. Everyone’s impatient—you are not alone. We want change to have already happened. And we want to be done with the struggle of eating—eating enough, not eating too much, eating just right. We want to be free of the rules and the thoughts, but are reluctant to invest the effort and time to enable it to happen. We make change, but it never seems good enough, and when it seems to be going along just fine, we fear we’ll slip up—and maybe we do. Quick fixes allure us, offering such promise. But this is not about quick fixes.

I’d like to wave my magic wand and make it all better. I do have a magic wand, but I’m saving it for when all hope is lost. And really we haven’t reached that place.

I’ve never built a house, but this analogy has crossed my mind many times. And you know once something is in my thoughts it’s challenging for me not to share!

Railroad house, Swiss Alps

Consider building your house

It starts with the foundation, which needs to be rock solid, firmly planted. Poured concrete, perhaps, definitely strong—at least after it has had some time to cure, to dry and set. And you’ve got to wait for that.

You could slap together some shoddy construction and it could look just fine on the outside—at least for some time. It may appear attractive at first, but with the first storm the siding may fall off, and the paint may begin to chip. The damage begins.

Restorations may take even longer. There’s some necessary destruction of the existing structure, which precedes the new construction, the rebuilding. And you have to pick and choose what you want to keep and what you’d like to discard in this new dwelling.

Such is the case of building a healthy relationship with food.

It takes time. After all, it took a long time to get into the mess you’re in now. And it takes a solid conviction that change needs to happen—because you believe in the need for change, not just your doctor, or your husband or your mother.

Return to trusting your hunger and your body’s ability to self regulate, if that was a part of your history, if you had once had a normal relationship with food. Remember how charming the old wallpaper looked and how comfortable it felt being in that space? Wasn’t it nice to be able to eat a couple of cookies or a piece of cake, without the negative self talk?

Or, was there never a normal relationship with food?  Was it always a relationship of shoulds and rules? Did you never feel safe listening to your internal cues? No feng shui when looking at the wall colors of the past rooms? Sure, it’s more challenging restoring, having never followed your internal compass—getting rid of the old thoughts and habits, and redirecting toward healthier behaviors.

Discarding old beliefs and unhealthy views requires some trust that your house will still be able to stand, without the supports of unhealthy rituals and black and white thoughts. The new pieces of information get tried on, sampled, then permanently attached, as you see their value and beauty.

You need to be able to weather challenges. Stressors, like strong winds and snow, can knock you down. But the more solidly you have set your foundation, the less damage will occur. For instance, keep structure to your day’s eating versus skipping meals. You’ll feel less vulnerable and therefore better able to handle the stressors. And remain fixed in the belief that yes, you are worth it, you do deserve to feel well, to take care of yourself, to eat. These are your cement.

It may take some time for these foundational principles to set, but adding supports can help.

Actually, he's a Swiss Alps goat farmer, but whatever!

Who are your craftsmen? Those who you select to labor on this building with you, whom you rely on to direct your project and provide a vision?

Select a team of with experience—your MD, therapist, RD. And surround yourself with laborers that have the same vision and can support your project, not pro-Ana sites, or diet programs failing to address your behaviors and thoughts.  Contract with friends and bloggers who can assist you in getting the building done, and can support your repairs as soon as they need to happen.

Building this chateau (Chenonceau) over water 
must have required great vision.

Quick fixes, like sloppy construction are destructive. I’ll just restrict now (and deny my hunger), just for this week, she told me, or just until the holidays, he stated. It’s like leaving off the insulation and expecting you’ll still stay warm. Okay, perhaps not so bad at first. But then the pipes freeze, and then burst, and now you’re left with major water damage and repairs to be done. After restricting, you may eat more than you intended, and then purge, or continue to restrict. Now your signals get confused, and distinguishing hunger and fullness is a challenge. Trust is lost, and your ability to self regulate. Never mind the damage to your body, your emotional state, and your belief in yourself. The thermostat stops working.

But it can be repaired

This medieval castle in Carcassonne, France was partially
reconstructed. Turned out well, no?

Repairs? Yes! Because slips happen (a new bumper sticker, perhaps?) Over time, damage may occur—a tree may come crashing into your house, a window may need replacing. Slips are a normal part of maintenance. But wait too long to work on quality repairs and soon the wiring will also be affected, or the cost of getting the work done will be too great. I can’t miss work to do an eating disorder program, can I? Or I don’t have time to see my nutritionist and my therapist regularly!

Don't hike up Peyrepretuse, in France, unless
your house is solid.

Remember, it gets way more costly putting off construction and renovation of your house. Consider starting now, from the ground up. Gather your team, and start pouring your foundation. And take the first steps to drafting your blueprints for a better relationship with food.